PEMERINTAH PROPINSI JAWA BARAT

RSUD JAMPANG KULON

Nama : DPJP :
Nomor RM : Diagnosis Masuk :
Jenis Kelamin : Tanggal Masuk :
Tanggal Lahir : Pindah Ke Ruang :

FORMULIR TRANSFER PASIEN

A. Ringkasan Riwayat Pasien

1. Anamnesis
a. Keluhan utama
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b. Riwayat Penyakit
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2. Pemeriksaan Fisik
a. Tanda-Tanda Vital
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b. Keadaan Umum
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c. Alasan Transfer
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B. Pemeriksaan Penunjang Yang Sudah Dilakukan
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C. Tindakan Medis Yang Sudah Dilakukan
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D. Pemberian Terapi
1. Cairan Infus
2. Obat Injeksi dan Oral
a. ......................................................... f. .........................................................
b. ......................................................... g. .........................................................
c. ......................................................... h. .........................................................
d. ......................................................... i. .........................................................
e. ......................................................... j. .........................................................
3. Derajat Kebutuhan Perawatan Pasien
Derajat 0 Derajat 2
Derajat 1 Derajat 3

KATEGORI PASIEN TRANSFER

Level Kategori Pendamping Peralatan
0 Pasien membutuhkan ruang perawatan biasa TPK/Petugas Semua rekam medik,
Keamanan hasil pemeriksaan
penunjang, format
transfer internal
1 Pasien beresiko mengalami perburukan, pasien baru Petugas PK 1 Peralatan derajat 0,
pindah dari HCU/ICU, pasien yang akan dirawat di Petugas Keamanan tabung oksigen nasal
ruang perawatan khusus kanul, stand infus dan
pulse oksimetri
2 Pasien memerlukan pengawasan ketat atau Dokter Peralatan derajat 1, bed
intervensi khusus. Misalnya pada pasien yang Perawat PK 2 side monitor, syringe
mengalami kegagalan satu sistem organ pump
3 Pasien mengalami kegagalam multi organ dan Dokter Peralatan derajat 2, alat
memerlukan bantuan hidup jangka panjang Perawat PK 3 bantu nafas
ditambah dengan kebutuhan akan alat bantu nafas
 PEMERINTAH PROPINSI JAWA BARAT
RSUD JAMPANG KULON

E. Kondisi Pasien
Sebelum Transfer Sesudah Transfer
Keadaan Umum : Keadaan Umum :
Kesadaran : Kesadaran :
Tekanan darah : Tekanan darah :
Nadi : Nadi :
Respirasi : Respirasi :
Suhu : Suhu :
Catatan Penting Catatan Penting
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Petugas Yang Menyerahkan Petugas Yang Menerima

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